Sunday, November 23, 2008

The Disease Management Care Blog Pauses While on the Way to the DMAA Meeting

In a compelling anecdote from the New England Journal of Medicine, a primary care doctor demonstrates the value of a personal physician by describing how she protected a fiercely independent elderly woman from the best intentions of a family and a health care system that would have otherwise gone amok. Talk to any doc and you’ll hear many stories like this. It’s an honor to be valued guests in other people’s lives at such times.

Here’s a story from the Disease Management Care Blog. Details are changed but the fundamentals are true:

It was the first day of my turn as attending on inpatient general medicine rounds. As usual, my team of residents, interns and medical students started rounds in the intensive care unit. One patient was a truly unfortunate young person who had been permanently injured as a result of a motor vehicle accident. Our duty was to preside over the countless details of care, anticipating that transfer to another hospital would happen in the not too distant future.

And that moment couldn’t come soon enough. Starting each day of rounds in that ICU was awful because the patient was smart, manipulative, angry and, most of all, depressed. The usual professional counseling and medication trials really didn’t have much of an impact on attitude and mood: the morose lack of eye contact some days, blubbering other days, refusals of care at times. Countless questions about details that only led to more circular questions took its toll on everyone. In the middle of it all, I repeatedly turned to my usual stock phrases that encouraged the patient to get through this, that persons learn to live with disability and, with time, this ICU would be a distant memory in a renewed life filled with new possibilities etc. etc. Deep down inside, however, I believed from years of experience that this person had been screwed and that life would suck.

The transfer eventually happened. We filled our days with other disasters until, after three weeks, I exited inpatient rounding and returned to my outpatient clinic.

Years later, after many other inpatient rotations, I was plotting my escape from rounds. Fewer of my physician colleagues were willing to do it, call was more frequent, and the ever increasing numbers of patient admissions was turning into a game of emergency room throughput and decreasing the length of stay filled with more and more patients with incurable chronic illnesses. Should I trump my growing administrative responsibilities? Seek other sources of clinical or research income to prop up my salary? Follow my spouse’s advice and draw a line in the sand? I steeled myself for a showdown with the Chair.

The mail pile of pharmacy reports, updates, memos and meeting notices on my desk beckoned as usual. In the middle of it was a card with a generic cover and a simple cursive hand written note that said: “You were right. I’m feeling much better.” I had to retrieve the medical record to recall the person who had signed it. It was the hopeless patient from the ICU.

I hung in there in inpatient rounds for several more years. I still have that card.

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